Dr. Tjorvi Perry – Chief of Cardiothoracic Anesthesia at the University of Minnesota Medical Center

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Dr. Perry is the Chief of Cardiothoracic Anesthesia at the University of Minnesota Medical Center in Minneapolis. He completed his anesthesia training and subspecialty training in cardiothoracic anesthesia at the Brigham and Women’s Hospital and Harvard Medical School of Medicine, where he went on to receive his Masters in Clinical and Translational Research. His current professional focus is understanding how what happens at the intersection of human behavior and complex systems, such as the cardiac operating rooms, impacts professional satisfaction and personal wellbeing of the physician, and safety and clinical outcomes of the patient.

At this years’ Annual Society of Cardiovascular Anesthesiologists Meeting in Chicago, Dr. Perry delivered a talk titled “Art to Automation; Reclaiming Our Presence and Intuition in the Operating Room” with the aim of shedding light on the complexities of adequately caring for the critically ill in our current clinical setting, and elevating the conversation around how we might leverage existing and in-coming technology in ways that might augment the performance of our clinical care teams.

Dr. Perry is always looking for value-added conversation with anyone, medical or not, that might add perspective on this very relevant and timely issue. He can be reached or followed through Twitter; @teperryMD.

Interviewer: Omar M. Khateeb, Director of Growth at Potrero Medical

Interviewee: Dr. Perry

Khateeb: Hi everyone. This is Omar M. Khateeb, the director of growth over at Potrero Medical. I’m at the Society of Cardiac Anesthesiologist here in Chicago and I’m joined with Dr. Perry. Dr. Perry, thanks for joining us today.

Perry: Yeah. Nice to be here.

Khateeb: Fantastic. It’s been quite an interesting conference. You had a really interesting lecture and session. Before we get into that, we want to get into your background and what brought you into medicine. So tell us a little about yourself.

Perry: Yeah, I did my medical school training in Iceland. That’s where I’m from originally. My father was in medicine so I followed in his footsteps and went into medicine myself. After my medical school, because I was a foreign medical graduate, I wanted to get into the best residency and fellowship and have the best training I could. So I committed myself to about three years of research fellowship and I ultimately went into anesthesia.

Khateeb: What kind of research did you do?

Perry: Well, it was interesting. I knew I wanted to do something with the heart and at the time I knew of a guy who was into tissue engineering. It was this regenerative organ medicine that he was doing in which was a big hub in Massachusetts, Boston.

And so I ended up working for a congenital cardiac surgeon who was tissue engineering heart valves. He had a lab where he had a grant to do these things. I joined his lab for about three years and we did some really fun stuff. I think one of my first papers was about making blood vessels. We’d put them in Sheep and then took them out . We looked at the histology and the reality and those kinds of things.

A lot of the work was around making heart valves and footwork for pediatric patients who sometimes are born with pulmonary valves that are either atretic or closed. So, they’re replaced pretty early on in life say within a couple weeks of life. As you might imagine, traditionally they get biomechanical valves and those valves don’t grow with the patient. The idea was to develop a tissue-engineered valve that would grow along with that baby so they wouldn’t have to come back for additional operations.

We developed scaffolding that was biodegradable. We found cells that we could seed onto the scaffold. As you might imagine, that tissue would grow as that scaffold disappeared and then you have basically a tissue valve. We looked at a few different cell types. We got stem cells from bone marrow. It was a long time ago but it was a very cool work.

Khateeb: It must have been very exciting especially doing that a long time ago.

Perry: We ended up making valve. The scenario was we took bone marrow out of Sheep.

Then we grew the valve and then we put that valve back into that same Sheep. Then we took them out after a few months at least and then looked at the histology. It was interesting to see. Once you put that valve in and it’s subjected to all the pressures and the flows, it starts to take on, histologically, a lot of the structure of a normal heart valve.

Khateeb: Interesting.

Perry: Yeah, it’s fascinating stuff.

Khateeb: Yes, it’s very fascinating.

Perry: It really got me to understand research methodology and how to ask questions: What’s viable? Where are the barriers? How do you build teams? I mean a lot of these things that I still use today.

Khateeb: What was the most memorable lesson you got out of that kind of experience?

Perry: That’s a great question. I would say it takes a certain work ethic and a commitment because it was translational work. In that lab, it was it was almost basic research all the way to a bedside for sheep. When you’re growing cells and your seeding these valves, that usually came first and I’m sure my wife felt that. [Both laugh] I mean, there’s a certain commitment and intensity that you have to bring on both short-term and long-term basis in order to see something like that through.

For better or for worse, I felt that I’d take that with me.

Khateeb: interesting. Now I’ve got one other question. You mentioned that your father was a physician.

Perry: Yeah.

Khateeb: My father was a physician as well. He was a surgeon. When you were younger, what was it about medicine that made you want to go into it? And as you got older as a young man, what made you commit to keep going into medicine?

Perry: Well, that’s a good question. My dad’s a Pediatric Cardiologist and he’s an internationalist. He was working at a time in the ‘80s where Boston Children’s Hospital was doing some amazing work for these kids that were born with Tetralogy of Fallot and atretic aortic or pulmonary valves and ASDs and BSDs. They were moving from taking care of these patients surgically to a catheter-based interventional therapy. I had an opportunity in high school to work as a technician in the cath lab. To see the level of commitment from those physicians and nurses and surgeons was profound for me. Although, it took me a while to get there obviously because I was young and stupid, I could see that their kind of purpose was super meaningful. I dabbled in business initially during my undergraduate years and I just wasn’t feeling it, so I did what I had to do to get into medicine.

Khateeb: I know, that’s very understandable. I think that I can say this for many of us both, for healthcare professionals and for those of us in the industry that we get into this field because it’s a very noble calling. Pun intended, it takes a lot of heart and a lot of persistence and consistency to fail and figure out not only what works, but what’s also going to be ultimately best for the patient.

Perry: I’d put in a plug though, for wellness.

Khateeb: Yeah, please do.

Perry: What I was seeing back in the ‘80s in their level of commitment was three standard deviations away from what’s good for the provider. It was night and day that they spent taking care of these patients. If you don’t take care of yourself you’re going to go down in flames and I think we’re seeing that.

Khateeb: That’s a very interesting concept. because it’s a multivariate problem. Physician burnout as an all-time high and a very ugly and dark part of that is that it, physician suicide rates are very high. I think there’s this archetype in medicine about physicians and nurses really putting themselves in harm’s way by losing sleep and not taking care of themselves well because they want to sacrifice to the patient, but your point is that you have to take care of yourself first before the patient. Tell me a little bit more about that.

Perry: When I was little, I used to fly back and forth from Iceland all the time because my dad’s American and my mom’s Icelandic. From the time I was three, we would travel back and forth. Almost every time, as the oxygen mask drops out of the top the stewardesses would say clearly that they want the parents to put the oxygen mask on first and then take care of the child. That never made sense to me at the time. Why, as a parent, wouldn’t you first put the oxygen mask on your kid? It wasn’t until recently that I understood the significance of that right?

If you can’t take care of yourself, you’re not going to be able to take care of the people around you. I’ve heard that metaphor used a number of times but it reminded me of how confused I was at the time that parents would do that.

I think if you grow up in an environment where you see the physician and the nurses completely focused on the patient with no regard for themselves, then that’s what you’ll emulate. I think it’s healthy for this generation coming into medicine to hear from people who have been through this: “Go, take care of yourself!” Figure out a real self-care plan.

Don’t go to the gym and try to be your last deadlift or something. That’s not self care. It’s being intentional about sitting with yourself and understanding what you’re going through and admitting some of its hard and some of its fun. Until you do that, you’re at more risk than less of anxiety, depression, burnout, impostor syndrome and suicide.

Khateeb: Do you feel that this culture in medicine where before you become a physician, you have to walk through the fires of hell in training is adopted in terms of how hard the training is and as a result, physicians just turn around and do the same thing to themselves, feeling that it’s normal?

Perry: Yeah, I think so. You know, it’s the fish that can’t see the water around them.

Khateeb: Hmm.

Perry: I think it’s up to us to pause and pivot. It’s a great opportunity. The conversation we’re having even at the societal levels is geared towards taking care of the provider so the provider can take care of the patients. And these are the models that we’re seeing in institutions too.

Khateeb: That’s a good way to jump off point to your session. I want to start by asking you this question that you address in yesterday’s talk. Where are we right now in medicine?

Perry: Well, I can speak from where we are in cardiac anesthesia, predominantly in the operating rooms and a little bit in the ICUs. I take my patients up and check out on there. Although, I don’t work in that environment, it looks a lot like the operating rooms.

I think we’re at a place where there’s a real imbalance between why we got into medicine (or why we think we got into medicine) and what we’re actually doing day to day. What I mean by that is, let’s assume that we’re highly driven, we’re type-a, we like the winds and then succeed and we like affirmation and all that. However, if you stay in medicine, it’s probably because you have a willingness or an ability to care deeply for your fellow man and you’d like to see them get through X, Y, and Z. What’s happening is that that has been set aside, maybe not intentionally, but because the complexity of care has become so great that if we don’t do all those tasks that we need to do in order to get through the day, we know that the patient will suffer. We’re not totally sure if empathy is going to get them through the day, but I know that if I don’t do X, Y, and Z in terms of tasks, the patient definitely will not get through the day.

So, I think it’s a bit of a gamble, but we’re willing to sacrifice some of that care and empathy that we got into it in the first place to make sure that stuff gets done. That has happened very quickly and there are different reasons why it has happened. I think we’re in an age where we’re seeing a lot of technology both hardware and software coming into the operating rooms within the hospitals.

I think we’re at a Crossroads where we’re seeing sicker and sicker patients, older and older and physicians are in a unique position because the ratio between physicians and non-physicians that’s around that patient have never been higher.

I showed a picture in my talk yesterday. It’s a painting called The Physician. It was a physician that was sitting with a patient and there was no care team. He probably got there by horse and buggy, and it was just that single physician and that patient. If you go into an operating room now, there are five disciplines that are actively working. Two of those are physicians but that ratio is getting less and less. So, what is our role?

There’s a bit of an identity crisis, especially between anesthesiologists and CRNAs and we wonder : “What’s the difference in the quality of care?”. I know it’s contentious and it’s a hard thing to talk about because you’re talking about your livelihood where there’s a lot of stock cost bias. There’s also so much that you put your time and effort into and here comes another profession that can do the same thing as you. I agree that it’s possible, but I think we have to look at that, sit with it and talk about it.

Khateeb: Mmm. You said something right now which is very interesting. You said there’s a change in identity. One thing that I’ve noticed when speaking to different physicians?one of which was Dr. Gordon Moorewood yesterday?is that he pointed out that a few decades ago, there weren’t as many different technologies, there weren’t as many different diseases but it seems that as we’ve developed these new technologies, there’s been an explosion of it. It’s like when maybe a few centuries ago someone first looked through a microscope and realized that a water droplet had millions of organisms in it.

In doing that, it seems that there’s almost an overwhelming amount of things to deal with. Something in that painting you showed yesterday that really struck me was that the physician was very intently and intensely focusing on the patient. I don’t think we see that too often today because physicians are spending more time with technology. Is that correct?

Perry: Yeah. The picture I contrasted that with was a picture of the operating room where we stand in anesthesia. It was just chaotic with monitors, drug delivery systems, and the echo machine in there. I mean, I would venture to guess that the public has no idea of what that looks like and I’d be a little hesitant in showing them that this is our workspace. My point with this and this should hit home with a lot of anesthesiologist is that because we’ve been flooded with technology in ways that haven’t necessarily been as intelligent, it hasn’t been very helpful. That’s not to put anybody down it just doesn’t seem very intentional the way we develop and introduce technology. What you get as a result is we have up to 40 bits of information on one screen times 3, 4, or 5 screens.

You’re talking about hundreds of bits of information. If you can imagine, there’s no depth to that information. So, as a physician, I’m obligated to look at 100 bits of data all the time. What I mean by depth is, if there’s a bit of information that’s not important at the time, it still shows up.

If we could develop technology that gives me information through any one of my senses but does it in an intelligent way where I can tell the difference between what’s important and what’s not, that way we’re getting at an automated way for me to take in information, interpret it, and then deliver the right kind of care.

Khateeb: Versus right now where it’s a constant flow of information.

Perry: Right.

Khateeb: I mean, forget about physicians. Human beings are not used to?from an evolutionary standpoint?digesting and dealing with all these types of information. Most especially, as human beings, we all have different biases. What might be important for you is going to be different for someone else. This is not because one’s right and the other is wrong, but again it’s about different training, cultures, biases and patients.

Perry: Absolutely.

Khateeb: So you described a very task centric world in your talk yesterday. It was a packed house and a lot of people really enjoyed it and I feel like you could hear a pin drop in there. You talked about moving away from a task centric world and empowering the physician’s intuition. Tell me more about that.

Perry: Yeah, this gets into wellness. I did a lot of reading on this subject and when I proposed this a year ago, I didn’t fully grasp the magnitude of this topic. It can go in so many directions and there are people who have developed a career around thinking about these things.

However, there’s also a lot of stuff on the internet that is valid but it’s mostly opinions. I tried to represent the perspective but at some point I just felt like I needed to take an opinion on why we need to start thinking more intentionally about automating. It might have felt more like an editorial than a primer or an informational session.

As I was contrasting those two pictures of the physician sitting under candlelight with that patient and the other one showing chaos that we’re in, it occurred to what my day looks like. From the time I come in to the time I leave, it’s basically just getting through things that I need to do and doing them in the right order so that the patient makes it through the surgery as effectively and efficiently as we can get. There’s very little time for just being present. I have had the opportunity over the last few years to think more about that piece. However, it takes training outside the operating room to bring that presence back to the operating room. You have to you have to start delegating, you have to start managing tasks and you have to be very intentional about the tasks that you’re going to do.

It’s not necessarily about decreasing them, but it’s about optimizing them. If you really look at our workflow, it can be very inefficient. So, I’ve tried to make my workflow as efficient as it can be in order to optimize the tasks. In so doing, I can just feel that I have opportunities during the procedure and during my day where I can be in the operating room, which is new to me.

Khateeb: You mentioned earlier that going through medical training, you have to learn how to have a lot of confidence because you’re dealing with human life.

Perry: Yes.

Khateeb: Somehow, the ego creeps in there and I think that’s where you start having to manage all these different data points. However, it sounds like because of necessity you had to learn how to get back your intuition to feel and understand what’s important and what’s not, is that correct?

Perry: Yeah, that’s right.

Khateeb: When did you first notice this?

Perry: I had an episode of burnout and I had the diagnosis.

Khateeb: How did you know that you were burned out? [Perry laughs] And I’m asking because so many so many physicians out there are probably burned out but they’re ignoring it. So, if you don’t mind telling us.

Perry: Well, it’s different for everybody. One of my professors used to say: “You’re different but you no damn special”. No, rather: “You’re special but you’re no damn different”.

Khateeb: That’s a good one. I’ll have to use that with interns. [Laughs]

Perry: We are all special but we’re not different, right? I went through some changes in my life. And ultimately it was me who put all this pressure on myself to succeed and to push in order to make the program better. The way it manifests for me is through aggression, agitation, frustration and anger. I see now that as angry as I was at other people around me, it was how I was treating myself. I was my own worst enemy for a while and it was impacting my family and my work environment to the point where I just needed a timeout. This was made clear to me by people outside of me.

I remember distinctly feeling like everybody around me is burned out and never did I think that maybe I’m being impacted as well. It was distinct events that brought my attention to the point where I couldn’t ignore it anymore.

And that’s when I really started becoming intentional about self-care and began re-examining questions like “What are the things that I want to be doing?”, “How do I want to be doing them?” and “How do I want to be communicating?” That’s a daily commitment and recommitment.

I grew up with this saying and you might identify it, especially in the western world: “There’s a stepwise fashion of getting to places”. You’ll start off on the lowest step and progress higher.

This is the “totem pole” thing that we’re always talking about, right? But I found that at least my. emotional and spiritual life are not like that. I may be able to draw out the accolades and affirmations that I’ve gotten?in a stepwise fashion they’ve gotten bigger in size and quantity?but my emotional and spiritual path waivers back and forth. Sometimes I’m in the dumps, and sometimes I’m not in the dumps, and that changes from day to day.

However, for me self-care or wellness is to be able to sit with that. Whereas, before if I was in the dumps and something wasn’t working, my head goes down and I push through it.

Khateeb: Interesting. What’s interesting about your talk yesterday was that it was a talk about intuition, automation and technology and you mentioned that you had changed the title many times.

Khateeb: Yeah.

Perry: You started with one title at the beginning of the talk and you ended with a very interesting one.

Perry: The idea was like how do we get from the art of medicine to automating everything. About a year and a half ago I had this idea that we could just automate as much as we possibly could and that would be cool. And then when I started looking at this and really thinking about it and talking to people, the art piece of medicine is that gut feeling

Khateeb: That intuition?

Perry: Right.It’s like you have that feeling where you’re like: “God, I think I’ve been here before! Something’s going to happen right now in the O.R. and I need heighten my alerts.”, right?

If you can’t access that, then what good is all your experience? You’re going to miss it. So, the idea is let’s take the mundane stuff that I didn’t go to medical school to think about, get that off my plate and make room for an ability to sense when something’s going to happen.

I’m sure that most Industries have something like that. I’m sure financial guys, accounting trial lawyers have that. There’s something they pick up on whether it’s an energy in the room, a body language or something that somebody says?were they know something’s going to happen there, and I think I know what it is.

Khateeb: I agree. It’s interesting that we joke about it in medicine that it takes so long to adopt something that’s been used for so long in other Industries. However, if you look at the billionaire Warren Buffett, you can go through multiple market reports, investment sheets and everything, but he always talks about how strong his intuition is. I think he’s in his late 80s or maybe close to his 90s now and he must be very strong and you can’t necessarily teach that.

Do you feel that with the explosion of technology in medicine with all of these sensors and robotics, that physicians are extending themselves technologically to be better at sensing all these things but the real importance of this is to get off these “mundane tasks” so they can focus more on higher level things?.

Perry: No, I think what I’ve seen anyway is a general resistance to technology. If you go into any operating room in the country, 75% of the monitors got there despite the physicians. They either got forced there by a single stakeholder or administration who read something and they wanted that monitor in there.

My opinion is that physicians are digging their heels in on all this technology.

Perry: “I don’t need it, I’ve been doing this for long enough.” “Show me the randomized controlled trial.” I think those responses are all manifestations of something deeper and that’s a hard conversation to have, especially when you’re getting into fear, shame and other intense feelings like that.

I don’t mean to be dramatic but if you’re suggesting to a physician that this technology. will help you manage X, Y, and Z. Then they start using it and that X, Y, and Z is actually 180 degrees to what they’ve been doing for the last 20 years, it suggests that they’ve been doing it wrong for 20 years. That’s a hard thing to settle with considering the number of patients that they’ve impacted in a negative way and it’s very understandable.

I’m not sure how you get there. I think it starts organically but it’s conversations that need to be had about “Where is this resistance to disruptive technology coming from? It is autonomy and it is job security and all that stuff but on a deeper level, it’s a deep-seated fear of being wrong, right? Or having done the wrong thing. That usually starts between two people and then over time it becomes a discussion point.

I think we’re seeing it more in the society level. I don’t know that we’re having that deep meaningful conversation with the increase in these guidelines development. The other half of guideline development and content development is implementation.

We’re really good at developing content but we’re not that good at implementing. The whole basis of implementation science should be a team of psychiatrists that come in and talk about your mom and what happened to you when you were 3 in order for you to be able to implement some technology/ [Laughs] It’s getting there.

Khateeb: When it comes to technology one thing that is being talked about more these days is the use of Artificial Intelligence and not only in the operating room but let’s say that the EMR with a variety of things to gain more insights, you know, be more “efficient”.

With cardiac anesthesiologists, do you feel that the resistance that’s there is coming from a point of fear or shame?

Perry: I think there’s a fear. There’s skepticism, but my sense is that it’s a skepticism with an asterisk. I mean, there’s something else going on where physicians are resistant to thinking about these things. On a very realistic note, in order for you to get into Artificial Intelligence and Machine Learning and all these things, you need enormous data sets, right?

Khateeb: And you need good data.

Perry: Yeah. It needs to be good data and we’ve just recently started collecting data in a format that it can actually be extracted. If you read Eric Topple’s book, Deep Medicine, I think he lays it out pretty fairly that there are pieces of medicine that might lend themselves to Artificial Intelligence, but for the most part.

Now’s the time to talk about it. I’ll segue into something that you were talking about before about all this technology that’s coming into the O.R.s. We’ve had very little to do with it.

Industry has been good at getting physicians’ opinions early on, and you might have some insight on this. They kind of get what the physician needs and then they go give those blueprints to an engineer. The engineer disappears for a couple years and comes out later with something that doesn’t look like what we actually need in the O.R.

That is nobody’s fault. If it’s anybody’s fault, it’s the physicians’ resistance to work with industry and you see that at some high-level places. The roadblocks to working with industry are huge but the unintended consequences are we have an O.R. full of machinery that nobody wants to use, nobody can use, the interface is silly and it’s not useful.

However, if you involve the team from the beginning all the way through that process, I think you’re going to start seeing way more intelligent technology that we can actually use and will benefit the patient and won’t add tasks, rather it’ll decrease the number of tasks that we have to do.

Khateeb: Actually, that’s the whole point of technology and my belief with technologies is that in medicine, the real purpose of technology is to help physicians return from whence they came. This is almost an anti-technology thing which means you should exist so that you don’t deal with it and it’s one less thing you don’t have to worry about so that you can go back to a scenario such as the one in the painting that you showed, where you’re focusing just on the patient versus playing with this shiny new thing.

Coming from a company that’s focused in the ICU, I’ve seen these photos where the ICU in the ‘80s and ICU today hasn’t changed.

Perry: [Laughs] It’s a bag of urine.

Khateeb: Yeah, exactly! There are wires everywhere, you know, and monitors. There’s just so much to look at. Do you feel like it’s the same thing in the cardiothoracic suite in the operating room between the ‘80s and now?

Perry: Yes, I do think that nothing has changed in the time that I’ve been in cardiac anesthesia. Sometimes when I am being present in the O.R., I’m able to see it and I wonder what other Industry is like this. When you start in Finance or Investment Banking, you start at the bottom with a cubicle. You try to clean it up and have it nice but as you know, it’s not a lot of space.

Then you can move up. At the end of it, you’re the CEO where you’re in the corner office; you got a view and everything’s taken care of. It’s a beautiful place to work and spend time. None of that has happened for me.

I worked in a piece of shit operating room when I was a fellow and I work in a piece of shit operating room now. [Khateeb laughs] I tell my staff sometimes that I’m going to wear a helmet the next day, because this is dangerous. I mean, we’re tripping over cords where you know monitor’s behind monitors. I can go on but if you’re going to start to objectify it, then you can see how ridiculous it looks.

Khateeb: It really is.

Perry: Yeah.

Khateeb: I was in a case a couple weeks ago where I didn’t know where to look because I was looking down to make sure I don’t hit a chord but I also had to look up so my head doesn’t run into anything. [Perry laughs] So, there’s a lot going on.

Perry: Yeah.

Khateeb: I don’t know how you can really do that.

Perry: I just wonder what the market is. You get a startup company from the valley to come in and say let’s just design an O.R. that looks like an executive suite in a corner office.

I just don’t know what the market is. I don’t know how big it is. I know healthcare industry is the biggest industry we have but the cardiac operating room is a sliver of that. The best we can do right now is to roll up our cords and make sure they’re not on the floor, make sure that the monitors are high enough that we’re not going to hit our heads on them, and make sure the hallways are clear so we’re not getting run over by carts. That’s about all we can do and I haven’t seen a lot of solutions.

Khateeb: This goes back to what you were mentioning with the use of intuition that maybe we can’t get away from it right now in terms of all these machines and cords, but perhaps there could be a way to design them so that you only interact with them when you need to; and 90% of the time they’re out of the way because you don’t need to be paying attention to them.

Perry: Yeah, I think that’s right. I would love to see that.

Khateeb: That would be that would be nice. We want to be mindful of your time but there are a few questions for you. This is my first time at a cardiac anesthesiology meeting and I talked with a few people yesterday about it and you too earlier.

One thing I asked a physician I can’t mention the hospital, all I’d say is he was a chair of cardiac anesthesiology at a very well-respected, world-renowned hospital? was: “What are some things that keep you up at night?”, and he mentioned heart failure, bleeding, and Acute Kidney Injury.

And Acute Kidney injury, even me being in med school, we didn’t talk about it because why talk about something that you can’t do much for. My company is looking into it. There are a couple of others who have done research and shown the value of urine output. However, when you realize that there’s a way to address a syndrome or disease, let’s say Acute Kidney Injury or sepsis, do you feel that most physicians are going to be hesitant deep down inside because it’s one more thing to deal with? What do you think that’s like when you illuminate a way to deal with something that hasn’t been dealt with before?

Perry: I think there’s going to be skepticism, but I can tell you my experience.

I stumbled upon this in more recent years. After my fellowship I was into genetics and we were looking at inflammatory markers and genetic predisposition to adverse cardiac events after bypass and things like that.

It was much more kind of translational clinical and I’ve become more interested in outcomes. As I started to understand outcomes research, I think you have to go upstream and there’s something that drives those outcomes. You can’t just focus on time to extubation and work towards that, there’s something upstream of that which has to be either managed, changed or standardized.

I’m taking a long ride around here. [Laughs]

Khateeb: No, we like the long ride on this show, trust me.

Perry: So, Acute Kidney Injury is a manifestation of poor hemodynamic management. I’m not saying people are doing something incorrectly, I’m just saying that if it’s not ideally managed [….]

As I mentioned in my talk yesterday, this is a complex system. There are pieces of this system that we certainly can’t see and some parts of the system that we don’t even know exist. So there are there are pieces of Acute Kidney Injury that we don’t quite understand or we don’t even have access to. However, I do think we have a fairly good idea that if you don’t manage your hemodynamics in a certain way, you’re more or less predisposed to kidney injury after cardiac surgery.

In that way, I’m interested in Acute Kidney Injury because it’s an outcome [….]

I have now some expertise in hemodynamic management that’s point-of-care directed in the cardiac operating room. Another big piece is you know post-operative cognitive dysfunction.

Khateeb: I saw it as a big topic

Perry: We’re starting to understand more and more in recent years that there’s a certain hemodynamic for which if you go below those things, you’re more likely to have some type of cerebral or cognitive dysfunction after surgery; which includes blood pressure, blood volume, after load and all those things. Hence, the same must apply for the kidney.

We’re starting to get a reasonable look at what end-organ perfusion of the brain might look like. We have monitors for that. We have Echo and EKG to see if there’s ischemia. And I’m talking about point of care things, not things like doing a thousand patients where we keep the blood pressure above 65 and then study those patients afterwards to see if there’s any cognitive dysfunction.

That is fine. It’s clinical work. It’s been done. I don’t want to see another paper on that.

I want to see point-of-care testing where we can react for that patient in the moment.

Khateeb: Interesting

Perry: What you’ve described with urine analysis is point-of-care testing. I can react to that patient and that’s that’s important to me.

Khateeb: Interesting. I was interviewing a nephrologist last year and I remember seeing this excitement around mobile ultrasound. I said why are nephrologists getting excited about Ultrasound? They kept saying Pocus: Point-of-care ultrasound

Perry: Yeah.

Khateeb: It seems that the technologies that are bringing the physicians back to the bedside and point of care is what they’re most interested in. Am I correct in saying that?

Perry: Absolutely.

Khateeb: Why is that? Do you think that it’s a subconscious move away from technology in using the right technology to bridge back to the bedside versus being at the computer?

Perry: Yeah, but I think it goes back to the picture. We want to spend time at the bedside and that’s why we got into medicine. There are very few physicians who have any kind of training in research. Most of those go a different route, they have their own lab, they’re doing PhD level work, and they’re chasing grants. They’re not in the operating room. Those papers might be coming out of a lab that’s involved in all that clinical research, but to be completely honest, they’re just not that useful.

I’m going to go out on a limb here and I’m going to say it.

Khateeb: Please do it.

Perry: I think we do the best we can but we have an academic promotion system that incentivizes papers. So you see people spending time in that clinical research space where they can look at X and see if Y changes, write it up, publish it and then move from assistant to associate to full professor. Whereas what we need to be doing is spending time in that transitional space in translating the clinical research that we already know and we’re always having to republish to how do we take care of that patient that I’m taking care of tomorrow.

The toughest piece of that space is getting humans to do what you think is right. So now you’re getting into human factors engineering, industrial psychology, how to interpret large data sets, IT and legal contracts with industry.

These are things that make people very uncomfortable and something that we definitely didn’t go to medical school for or get any training in medical school about.

It’s a big leap, but maybe as a society we need to start incentivizing efforts that come out of that space. Also, maybe it’s not about that traditional paper with an introduction, methodology, results and discussion; maybe it’s implementation efforts. I don’t know what it looks like, but I think it looks different than publishing a paper in a journal.

Khateeb: There was a talk yesterday with Dr. Gordon Moorewood about the business model of medicine.

I learned a lot just by sitting in that short time and talking with him. He mentioned that we should be getting away from the fee-for-service and that we’ve been incentivised to get paid on process and what it should be is product because if it’s just product, the process can be incentivized to be Innovative and changed.

Do you feel like that’s how it is even in the academic world? That publishing papers means that you’re getting rewarded for process and not product?

Perry: That’s very possible. I have a hard time wrapping my head around that piece. At some point. I had a stroke where money matters and reimbursement matters. I wish I had the passion that Gordon does about this stuff as well as the understanding that he has, but I don’t.

However, I do understand that I get paid for putting an arterial line in, but I don’t get paid for managing the blood pressure for the entire case as hard as that may be. Do I care about that? Again, I wish I did.

Khateeb: I think incentives

Perry: Yes you’re right. It does have to do with incentives. It’s a source of being undervalued. You know, my grandmother can put an A. line in but I don’t know whether my grandmother can manage the hemodynamics of an entire cardiac case that goes on for six or eight hours. So, am I being undervalued? Yeah, I think so.

Khateeb: We’re getting close to the end of this show and I want to be mindful of the time. Just one or two more questions. Can physicians return to using their intuition by using technology better?

Do you feel that it’s possible?

Perry: Absolutely. Over the last year since I’ve been doing this reading, I’ve become more convinced. A really good book I read that I’d recommend was written by Simon Sinek.

Khateeb: Start With Why?

Perry: Yeah, Start With Why. If you haven’t had a chance to read it, you could just take a glimpse at his Ted talk. For me, that’s the “Why”.

Why do you want all this technology now? Because I don’t want to do all the things that this technology can do and still do way better than I can. Not that I want to sit back and do nothing, but now I want to bring forth those things in me that I think can really help me and my colleagues get through the day, and it can help our patients do better.

Khateeb: It sounds like it’s the use of technology so that you can use what’s in you, which is this intuition and energy, to heal people. Sometimes, it’s looked like it’s wizardry, but these are things that scientists have still yet to be able to explain, right?

Perry: Yeah, the gut feeling is a real thing.

Khateeb: Interesting. The last question that already segued into it is, could share some book recommendations with our audience? I’m sure many of them would really appreciate it.

Perry: Yeah, I just got done reading Essentialism by Greg McKeown. Just Google “Essentialism” it really it’s a very cool book. It’s nothing new but he packages it in a way that just allows you to [….]

It talks about how to say ‘no’ to things. He talks about how to prioritize and focus on what it is that you really want to do. It’s a cool read.

The book by Eric Topol is really good.

Khateeb: Deep medicine?

Perry: Deep medicine. It looks like it’s a big book, but he writes so well and you can read it. I read it in a week and it’s a resource you can go back to.

There’s another good book by a legal duo father-son. Their last names are Suskind and Suskind. They write about professions and how professions are changing from the craftsmanship to packaging essentially. It really opened my eyes to how protective we are and the things that we do to protect our own professions when there may not always be a good reason to do that.

I don’t know if this is binary, but I see that we are digging our heels in on a lot of things as opposed to opening our doors and inviting non-physician providers to participate and for us to maybe teach and counsel and then move on to something else. Those are the big ones.

There meditation books and self-care books that I’ve gotten to read. Pema Chodron is one that I picked up. I mean she has like pamphlet-sized books but they just get really to the core.

Khateeb: Can you recommend one of hers?

Perry: I think it’s called “When Things Fall Apart”. It’s a book that you can read over and over again and you’ll always get something new out of it. I think that it probably speaks to the journey that we’re all on. It’s like when you get to a certain point where you have more experiences and now you have a different understanding. You’ll always connect with her words in different ways.

Khateeb: Fantastic. Doctor Perry, hey, it’s been incredibly fantastic and enlightening. I’m sure many of our listeners are going to be curious. How can we best find you online? I believe you’re pretty active on Twitter.

Perry: I try to be.

Khateeb: What’s your Twitter handle?

Perry: It’s @TEPerryMD.

Khateeb: Perfect, we’ll leave it down on the show notes.

Perry: I appreciate it.

Khateeb: Do you have any other social handles or websites?

Perry: Not right now. [Laughs]

Khateeb: One’s enough, right?

Perry: Yeah, I think so. My daughter’s 22. She’s on Instagram. Do you just say the full thing or IG? I don’t know.

Khateeb: Yeah. Yeah, Instagram or IG.

Perry: [Laughs] I don’t know how to use that yet professionally but I think that’s a great platform. I’ll work on that one.